Lymphopenia and decrease in the total number of circulating CD3+ and CD4+ T cells during 'long-term' PUVA treatment for psoriasis.

The relationship between high-dose PUVA treatment in psoriatic patients and peripheral T lymphocyte subsets (total number and percentage) has been studied. Of the two groups of patients considered, the first included 19 patients, all affected by chronic, progressively worsening psoriasis; they had never been previously treated by photochemotherapy. The second group included 13 psoriatic patients, who had received an average cumulative dose of 2,007.69 +/- 1,191.05 J/cm2. The 'long-term' PUVA-treated group was assessed while undergoing maintenance therapy. No significant differences were found between untreated patients and healthy controls for any of the parameters considered. A significant reduction (p less than 0.05) in the total number of lymphocytes in long-term PUVA-treated patients both versus untreated patients and controls was found. Furthermore, long-term PUVA-treated patients showed a significant reduction (p less than 0.05) in the percentage of lymphocytes as compared with controls. The reduction in the total number of CD3+ and CD4+ T cells was, moreover, significant (p less than 0.05) as compared with untreated patients. The impairment of circulating CD3+ and CD4+ T cells (total number) was only on the borderline of statistical significance vis-à-vis controls. These findings suggest the usefulness of a careful assessment of circulating T lymphocyte subsets in patients who undergo long-term PUVA therapy.     

PUVA suppresses the expression of cell adhesion molecules of lymphocytes

Abstract To determine the therapeutic mechanism of PUVA in psoriasis vulgaris, the effects of PUVA on activated T lymphocytes were investigated in vitro. Peripheral blood mononuclear cells (PBMC) obtained from healthy volunteers were activated with Con A stimulation (Con A blasts). Both untreated PBMC and Con A blasts were irradiated with UVA light in the presence of 8-methoxypsoralen (8-MOP). The expressions of CD4, CDS, VLA-4 and LFA-1 of PBMC and Con A blasts were stained with each monoclonal antibody and the intensity of fluorescence was analyzed by FACScan. PUVA-treated PBMC showed decreased response to both Con A and PHA stimulation. PUVA treatment also suppressed the IL-2 production of Con A blasts and IL-2 response of PBMC with increasing UVA fluence. The expressions of LFA-I, VLA-4, CD4, CDS and CD25 (IL-2R) molecules were decreased in PUVA-treated Con A blasts. Con A blasts were more sensitive than untreated PBMC to PUVA treatment. These results suggest that the therapeutic effects of PUVA on psoriasis vulgaris can be induced by suppression of the expression of cell surface molecules of activated T lymphocytes.     

Immunologic implications of PUVA therapy in psoriasis vulgaris

Summary During the combined effects of psoralen and UVA irradiation (PUVA therapy) a significant decrease (P<0.005 in T cells has been noted in 10 psoriasis patients and 10 healthy controls especially after four exposures. Based on the fact that the total number of circulating lymphocytes of the patients and the PUVA-treated healthy controls remained within the normal range, this decrease may be due to temporary physicochemical changes of the membranes of these cells but not to T cell lysis. After eight exposures these decreased T cell values returned to starting range. The starting T cell range in psoriasis patients is significantly lower (P<0.005) compared to that of healthy controls.It is of importance that before PUVA therapy in all the patients antibodies reactive with a basal cell nuclear antigen belonging to the four main Ig classes (IgM, IgD, IgE, and IgA) could be removed from the membrane of circulating lymphocytes by means of acid elution. In contrast, mainly the IgA antinuclear basal cell antibody could be eluted from circulating PMN leukocytes in the patients under investigation. After eight PUVA exposures, however, corresponding antibodies, belonging to the three main Ig classes (IgM, IgD and IgE) could also be eluted from the membranes of circulating PMN-leukocytes of the same patients. This implies an exchange of molecules during photochemotherapy. Finally, it could be shown that after effective PUVA therapy antinuclear basal cell antibodies of the psoriasis patients under study were reactive not only with the nuclei of the basal cell layer but also with almost all the nucleic of the epidermis of the uninvolved and lesional skin. The latter finding points to the fact that PUVA treatment causes at least antigenic changes of nuclear proteins in all the nuclei of the epidermis of the PUVA treated skin. Moreover, inflammatory cells with Fab fragments within the cells present in the lesional skin before PUVA disappear during this treatment.Based on a poster session presented at the occasion of the seventh joint meeting of the ESDR, Amsterdam, The Netherlands, May 1977     

应用单克隆抗体研究寻常型银屑病患者外周血中的T细胞及其亚群

以抗人T细胞表面坑原的单克隆抗体OKT3、OKT4和OKT8用直接免疫荧光法分析了进行期、静止期和退行期寻常型银屑病(各10例)患者外周血中的总T细胞、协助/诱导性T细胞和抑制/细胞毒性T细胞的百分数、以及OKT4⁺/OKT8⁺细胞的比率.10名正常健康人为对照组.结果发现,与健康人对照组比较,各期寻常型银屑病患者的OKT3⁺,OKT4⁺,OKT8⁺细胞数和OKT4⁺/OKT8⁺细胞的比率无显著差异(P>0.05),各期寻常型银屑病患者间亦无显著性差异(P>0.05).最后,对本研究结果进行了讨论,认为银屑病中所见的T细胞、抑制性和协助性T细胞亚群数的异常可能是一种继发现象.     

The cell population in the cutaneous infiltrate of mycosis fungoides: in situ studies using monoclonal antisera

T cell antigens were studied in cutaneous sections from five patients with mycosis fungoides (MF). The method allowed cell counting to be undertaken for each monoclonal antiserum. OKT3 (pan T cell) antiserum confirmed the predominantly T lymphocytic nature of the infiltrate, labelling the majority of infiltrating cells. OKT4 (helper/inducer) antiserum positively labelled 90% of the lymphocytes identified as OKT3⁺. OKT8 (suppressor) antiserum marked only single or small groups of dermal lymphocytes, which comprised 24% of the cells identified as T lymphocytes. OKT6 (anti-Langerhans) showed positive labelling of dendritic cells in the epidermis and dermis. Fewer positively labelled epidermal dendritic cells were observed in sections from patients receiving PUVA, but no difference was found in the number of OKT6 positive dermal cells. The ratio of helper to suppressor cells in the dermal infiltrate significantly exceeded the normal circulating ratio.     

Diagnostic criteria in Sézary's syndrome: a multiparameter study of peripheral blood lymphocytes in 32 patients with erythroderma

In order to define additional diagnostic criteria for the early diagnosis of Sézary's syndrome (SS), peripheral blood lymphocytes of 32 patients with erythroderma, including 8 patients with SS, 4 patients with erythrodermic mycosis fungoides, 14 patients with an erythroderma on the basis of atopic or chronic dermatitis, and 6 patients with erythrodermic psoriasis, were investigated by computer-assisted morphometry. The degree of nuclear indentation, expressed as the nuclear contour index (NCI), was measured on electron micrographs. The mean NCI and the percentages of cerebriform mononuclear cells (CMC), defined by a NCI greater than or equal to 6.5, were calculated. In addition, the percentages of lymphocytes, T and B cells, and the distribution of T-cell sub-populations as defined by Fc-receptors (T mu, T gamma) and monoclonal antibodies (OKT3, OKT4, OKT8, HLA-DR) were determined. Statistical analysis showed as most discriminating parameters for the differentiation between SS and benign forms of erythroderma: high percentages of lymphocytes (50% or more), an expanded OKT3+, OKT4+ population with an OKT4/OKT8 ratio greater than 10, a mean NCI value greater than or equal to 5.5, the presence of more than 20% CMC, as well as the presence of cells with a NCI greater than or equal to 11.5. The total leukocyte and lymphocyte counts, as well as the percentages of B, T, T mu, and T gamma cells had limited value for the early diagnosis of SS.     

Distribution of T-cell subpopulations in the peripheral blood of patients with erythrodermic psoriasis

In the present study the percentages of T cells and T-cell subsets, as defined by Fc receptors and monoclonal antibodies (OKT3, OKT4, OKT8, HLA-DR) were determined in the peripheral blood of 12 patients with psoriasis, including six patients with erythroderma and 6 with active, but limited disease. The patients with erythroderma were studied before treatment and 4-8 weeks following. The mean percentages of E-rosette-forming cells and T-cell subsets reactive with the monoclonal antibodies OKT3, OKT4 and OKT8 were within normal limits, as were the percentages of T mu-cells, irrespective of the extent or activity of the disease. The mean percentage of T gamma-cells was reduced in the patients with untreated erythrodermic psoriasis but not in the patients with limited disease. Comparison of the T gamma values in the erythroderma group before and after therapy showed a slight, but statistically significant increase (P less than 0.03). These results indicate a direct relationship between the T gamma deficit and the extent of skin involvement, and argue against a primary suppressor T-cell defect in psoriasis vulgaris.     

Bath psoralen+ultraviolet A photochemotherapy vs. narrow band‐ultraviolet B in psoriasis: a comparison of clinical outcome and effect on circulating T‐helper and T‐suppressor/cytotoxic cells

Background: Comparative success rates of bath psoralen+ultraviolet A (PUVA) and narrow band‐ultraviolet B (NB‐UVB) in psoriasis treatment are variably reported with no previous studies on the possible effect of bath PUVA on circulating CD4+ and CD8+ T cells. Objective: We aimed to compare the effect of bath PUVA and NB‐UVB clinically and on circulating T‐helper and T‐suppressor/cytotoxic cells in psoriasis. Patients and methods: Thirty‐four psoriatic patients divided into a bath PUVA‐treated group (18 patients) and a NB‐UVB‐treated group (16 patients) were compared regarding the disease severity by psoriasis area and severity index (PASI) score and percentage of circulating CD4+ and CD8+ T cells by flowcytometry before and after treatment. Results: After treatment, the bath PUVA group showed a significantly higher reduction of PASI score (85.44%) than the NB‐UVB group (58.72%). Mean peripheral CD4+ T‐cell percentage was significantly lower after [36.8; 95% confidence interval (CI) 33.80, 39.97] compared with before treatment (42.06; 95% CI 38.29, 45.83) (P<0.05) in the bath PUVA group while this difference was insignificant in the NB‐UVB group (P>0.05). Conclusion: Bath PUVA therapy is superior to NB‐UVB in the treatment of moderate and severe psoriasis with mild reversible side effects. Both modalities have a systemic effect decreasing peripheral CD4+ T cells, which is more with bath PUVA.     

Distribution of circulating mononuclear cells in short-term PUVA-treated psoriatic patients and healthy subjects

Peripheral blood mononuclear cells (PBMC), as defined by monoclonal antibodies (OKT3, OKT4, OKT8, OK 1, Leu 7, Leu 11b) were determined in 10 psoriatic patients and in 10 healthy subjects before and after administration of short-term PUVA therapy. A comparison of the mean baseline percentages of the two groups showed a statistically significant increase in Leu 7+ cells (p less than 0.001) as well as a slight increase in OKM1 and OKT8 positive cells in the psoriatic subjects. After 21 exposures, these subsets showed a reduction towards control values, while a significant increase in OKT3 and OKT4 positive cells (p less than 0.01) could be observed only in the control group. These results indicate that short-term PUVA therapy is associated with changes in PBMC subpopulations. This modification, however, does not necessarily imply a disturbance of immune system function, including natural killer activity.     

Abnormal lymphocyte function following long-term PUVA therapy for psoriasis

The surface markers and function of peripheral blood lymphocytes were examined in patients on long-term therapy with methoxsalen and UV-A radiation (PUVA). Ten patients with psoriasis were selected because they had received a high exposure to PUVA therapy, i.e., more than 200 treatments over 2–6 years with cumulative exposure doses of 1700–6000 J/cm² UV-A radiation. Results were compared to those obtained with lymphocytes from untreated patients and UV-B treated patients with psoriasis. The PUVA-treated patients had low levels of E rosette-forming cells in the peripheral blood and markedly impaired lymphocyte responses following stimulation with optimal and suboptimal doses of mitogens. The sensitivity of lymphocytes to in vitro treatment with PUVA was similar in the three groups of patients. The results of this study indicate that long-term PUVA therapy alters the function and cell-surface markers or distribution of lymphocytes.     

Evidence for CD8+ cell increase in long-term PUVA-treated psoriatic patients after PUVA discontinuation.

Long-term PUVA-treated psoriatic patients given maintenance therapy (UVA doses greater than 1,000 J/cm2) have been demonstrated to undergo lymphopenia and a decrease in the total number of circulating CD3+ and CD4+ T cells. The aim of this study was to assess whether the impairment of T cells is detectable also in psoriatic patients after long-lasting PUVA discontinuation. A group of 34 psoriatic patients (25 males, 9 females; mean age 52.7 +/- 12.82 years), who had previously been treated by PUVA therapy (average cumulative dose 1,898.48 +/- 1,207.12 J/cm2), was studied 1 year or more after discontinuation of PUVA therapy. The patients studied failed to show any impairment in CD3+ and CD4+ cells. Nevertheless, a significant increase (p less than 0.05) in circulating CD8+ cells (both in the percentage and the total number) was detectable in PUVA patients as compared to appropriate controls. The significance and implications of this finding are not known and need further investigations.     

Immunological aspects of psoriasis

We investigated sixteen patients before and after 1 month of PUVA therapy (three times a week) for circulating immune complexes (CIC) and T-cell markers. CIC were detected by the PEG-C4 assay, using a laser nephelometry determination of polyethylene glycol (PEG, 3.5%) precipitated endogenous C4. T cells were evaluated by E rosettes, active E rosettes, anti-HTLA serum and ox EA γ-rosettes. This latter method investigated mainly T cells bearing Fc receptors for IgG (Ty-cells). After 1 month of PUVA-therapy: (a) the cutaneous lesions markedly improved; (b) the mean percentages of E rosettes, active E rosettes, and HTLA bearing cells, depressed before treatment, returned to normal; (c) CIC were found in higher amounts; (d) T γ-cell numbers decreased simultaneously. The improvement of T-cell levels assessed by E rosettes, active E rosettes and HTLA values was correlated with clearing of skin lesions, as previously reported by others. However, the increase of CIC during PUVA therapy, their correlation with T γ-cell decrease, and their possible role in the pathogenic chain of psoriasis remains uncertain.     

Immunological effects of stress in psoriasis

Background Psychological stress causes phenotypic changes in circulating lymphocytes and is regarded as an important trigger of the Th1‐polarized inflammatory skin disease psoriasis. Objective To study the effects of psychological stress on immunological parameters, i.e. membrane molecules relevant to the pathophysiology of psoriasis, especially cutaneous lymphocyte‐associated antigens (CLA) involved in T and natural killer (NK) cells homing in on the skin. Methods The severity of psoriasis was assessed in patients using the Psoriasis Area and Severity Index. Patients with psoriasis (n = 15) and healthy volunteers (n = 15) were exposed to brief psychological stress in the laboratory. In vitro analyses were conducted 1 h before, immediately following and 1 h after stress exposure. Peripheral T‐ and NK‐cell subsets including CD8+ T lymphocytes, CLA+ lymphocytes and lymphocyte function‐associated antigen type 1 (LFA‐1)+ lymphocytes were analysed by flow cytometry. Results We found a significant stress‐induced increase of CD3+ T lymphocytes in patients with psoriasis only. Analyses of T‐cell subsets revealed that this increase was observable for cytotoxic CD8+ T lymphocytes and CLA+ CD3+ lymphocytes. The total number of circulating NK cells (CD16+, CD56+) increased immediately after stress in both groups whereas only patients with psoriasis showed a significant increase in CLA+ NK cells. Conclusions A higher stress‐induced increase of CLA+ T and CLA+ NK cells in the circulation of patients with psoriasis might point to an increased ability of T and NK cells in the presence of psoriasis to home in on the skin during mental stress. Further studies are needed to verify these relationships in more detail and to investigate the time point at which these cells accumulate within lesional skin, and whether or not psychotherapy improves the quality of life of patients with psoriasis and influences stress‐dependent parameters.     

Estimation of tissue osteopontin levels before and after different traditional therapeutic modalities in psoriatic patients

Background Several lines of evidences support a major role for Th1 cells in psoriasis. Treatment of psoriasis with cyclosporine, methotrexate and psoralen plus ultraviolet A (PUVA) is associated with clinical improvement and decrease in epidermal hyperplasia. Osteopontin (OPN) exerts a T‐helper type 1 (Th1) cytokine function, regulating inflammatory cell accumulation and function. Objective To detect the effects of methotrexate, cyclosporine and PUVA on OPN expression in psoriatic plaques, and whether these changes correlate with clinical response. Methods For three groups of psoriatic patients (each including 12 patients), the Psoriasis Area Severity Index (PASI) and levels of lesional skin OPN were determined using enzyme‐linked immunosorbent assays before and after treatment with methotrexate, cyclosporine or PUVA. Skin biopsies from 20 healthy volunteers served as control for OPN levels in normal skin. Results Baseline lesional skin of psoriatic patients showed a statistically significant elevation of OPN levels in comparison to controls. Three months after therapy, the three therapeutic modalities were associated with a significant decrease in the mean levels of PASI and tissue OPN, with the PUVA group showing the highest level of reduction in OPN levels and cyclosporine group showing the highest level of reduction in PASI. Conclusion Our study points to the possible role played by OPN in the pathogenesis of psoriasis and in reflecting disease severity. These standard therapeutic modalities used in the current study were associated with a significant decrease in PASI and OPN levels. They constitute highly effective therapeutic modalities for psoriasis, which might exert their anti‐psoriatic activity partially through altering the expression of OPN.     

Peripheral T-cell subsets in patients with alopecia areata in different clinical phases

An analysis of T-cell subpopulations was carried out in the peripheral blood of 21 subjects with alopecia areata (AA) of the scalp in various phases of its evolution and in 18 healthy control subjects by means of different monoclonal antibodies of OKT series (T3, T4, T8, T11). Patients with AA in active phase showed a significant reduction of OKT 8+ cells (p less than 0.002) and a significant increase of OKT 4+ cells (p less than 0.002) versus controls. On the contrary, patients with regrowing hair showed a significant increase of circulating OKT 8+ cells compared with controls (p less than 0.002). No abnormality in the distribution of T-cell subsets in patients with AA in stable phase has been observed.     

The occurrence of vitiligo after psoralens and ultraviolet a therapy

The ability of photochemotherapy with 8-methoxypsoralen in conjunction with high-intensity long-wave ultraviolet light (PUVA) to stimulate melanogenesis is well known. This effect on the pigmentary system is evidenced by the diffuse tanning of clinically normal skin in PUVA-treated patients with psoriasis and other disorders, as well as by the repigmentation of lesions in vitiligo. It is now recognized that there may be additional pigmentary effects, resulting in clinical lesions such as PUVA mottling, PUVA lentigines, and localized hypopigmentation. We have documented the occurrence of yet another association with PUVA therapy--the paradoxical appearance of widespread hypopigmentation consistent with vitiligo in three PUVA-treated patients, one with psoriasis and two with mycosis fungoides. Histologic and ultrastructural findings are presented.     

Effect of etretinate on peripheral T lymphocytes in psoriatic patients before, during and after 6 months of therapy

Total peripheral T lymphocytes, OKT4 helper/inducer cells and OKT8 suppressor/cytotoxic cells, as well as T lymphocyte function determined by the local xenogeneic graft-versus-host reaction (GVHR), were investigated in 14 psoriatic patients prior to institution of treatment with etretinate, during the course of treatment and 6 months after its initiation. After approximately 2 months of treatment, there was a significant increase in the number of E-rosette-forming lymphocytes and OKT4 subpopulations with a return to normal levels after 6 months of treatment. The GVHR was positive in only 5/11 patients prior to therapy but in 9/11 patients after 2 and 6 months. Our results indicate that etretinate has a stimulatory effect on T lymphocytes and their subset counts.     

Determination of circulating lymphocyte subpopulations in atopic dermatitis using monoclonal antibodies

Monoclonal antibodies were used to determine the level of circulating helper and suppressor T cells in 34 infants and adults with severe atopic dermatitis and in normal controls. The percentage of OKT3 (total T lymphocytes) was reduced significantly in all the atopic infants. The percentage of OKT8 (suppressor-cytotoxic T lymphocytes) was reduced significantly in all patients with active lesions. The percentage of T gamma lymphocytes was reduced in all the atopic patients with or without active lesions.     

Mononuclear cell phenotypes in patients with psoriasis

Mononuclear blood cells from 19 patients with psoriasis were stained with a panel of monoclonal antibodies which detect total T lymphocytes, their helper/inducer and suppressor/cytotoxic subsets and Ia-positive lymphocytes and monocytes. Fluorescence-positive cells were enumerated by cell flow cytometry. In these patients, percentages of all mononuclear cell studies were within reference range with few, sporadic exceptions. Statistical analysis of data showed no significant differences between patient values and reference values from a panel of 100 normal subjects.     

Transient impairment of peripheral blood lymphocyte function during PUVA therapy

Three parameters of immune function--enumeration of circulating T and B lymphocytes and response of lymphocytes to graduated doses of phytohaemagglutinin (PHA)--were examined serially in eleven patients with psoriasis before, during, and after an intensive course of PUVA therapy. A trend was detected for the lymphocyte response to PHA to fall during the first week of treatment and then rise back towards the pre-treatment level. No alteration was found in the percentage or absolute numbers of circulating T and B lymphocytes. This study shows that routine PUVA therapy can induce an alteration in immune function but that this alteration is slight and short-lived.